- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $6,165.95 / $16,218.10
| Facility | | $3,019.95 | $6,165.95 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,884.03 / $3,981.07
| Professional | | $2,344.23 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,897.79 / $16,982.44
| Facility | | $3,019.95 | $4,897.79 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $4,168.69
| Professional | | $1,445.44 | $1,445.44 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,888.44 / $15,488.17
| Facility | | $2,344.23 | $5,888.44 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,248.07 / $10,000.00
| Professional | | $4,168.69 | $5,248.07 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,630.78 / $4,365.16
| Facility | | $2,137.96 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $4,365.16
| Professional | | $1,513.56 | $2,137.96 | $4,365.16 |